Kingsley

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

The provider had not consistently embedded legislation and evidence based good practice into the processes at the service and there was a risk people would not achieve the positive outcomes they deserved. Staff were not always supported by a strong leadership team, they told us the registered manager was accessible and approachable but they were “isolated” from the provider who they rarely met. There was poor oversight of the service and the provider had not completed effective checks to assure themselves people always received safe support which met their needs and preferences. This had led to shortfalls at the service which the provider was unaware of and continued unchallenged. No action had been taken to continually improve and develop the service. Following our assessment the provider told us they had taken action to address the shortfalls we found.

Staff did not know how to mitigate some risks to people, including risks related to epilepsy. Other risks related to people’s health and personal safety were managed to give people as much freedom as possible. People’s medicines were not always managed safely. Some risks in the environment and infection control risks had not been identified and addressed. Nationally recognised guidance to support people to communicate their needs, wishes and emotions was not consistently used.

The service was isolated at times from the local learning disability community and there was a risk of a closed culture. People were not supported to access some community resources which they may enjoy to make new friends and try new experiences.

Some staff had not completed practical training in high risk areas, such as first aid and fire safety. Staff competence to complete other tasks had not always been assessed. Staff did not understand the goals of the service and a shared vision and culture had not been developed.

We found a breach of regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

People had lived at the service for a number of years and staff knew them well. Any changes in people’s health needs had been identified and staff had worked with health care professionals to get the treatment and equipment people needed.